O Tempora, O Mores: Affordable Care Act - Big Dream or Big Let Down?

I confess I was a strong proponent of the Affordable Care Act. My reasoning was subtler than the hallowed pantheons of its staunch supporters and the apocalyptic predictions of its detractors. Forty years after graduating medical school I concluded, after many stutter steps, the American healthcare delivery system was economically unsustainable and the citizenry was neither living longer, nor better, despite medical expenditures that dwarf any other developed nation. My career also allowed me to personally interact with cardiac surgeons from all continents and see that their clinical results and research efforts were laudatory by any standards.

It pained me to see the counterproductive hurling of inaccurate, invective, and promulgating fear and misinformation based on political ideology with no regard for attempting to confront the problems of the status quo. Obamacare is not, in fact, a revolutionary change in healthcare delivery; it is health insurance reform with a mandate for universal coverage that on the fringes promotes new reimbursement models, but mostly preserves, at present, a fee-for-service system.

What was potentially the most beneficial aspect was that a political third rail had been breached-- the medical-industrial complex was confronted and legislation was passed and judicially approved. Obviously the law was tainted, imperfect and inexpertly introduced. I was naive and felt it was a start; the first step had been taken and now we could start the process of actually improving healthcare delivery to everyone because it was now a premise that all were entitled to.

As Cicero so aptly lamented during his first Catalonian Oration, “O Tempora, O Mores;” what difficult times, how unethical the political climate. I still do not get my facts from viewing the Republican Presidential Debates, nor sound bites from right-wing talk radio. To the chagrin of my GOP friends, I subscribe to and read daily the New York Times. Two recent articles from the fountain of liberal mantras suggest that the Affordable Care Act is not working and this attempt at reform maybe significantly flawed. Our present administration may be more interested in painting rosy pictures than facing uncomfortable economic reality.

On January 6, 2016, the front page headline was “Medical Debt Often Crushing Even for the Insured”. Despite coverage by Obamacare, 20% of people too young for Medicare eligibility had having trouble paying their medical bills last year. They are still vulnerable because of the rising cost of coverage and covering 15,000,000 more Americans has accelerated the burden of copays and deductibles. That take-home message was reiterated and anecdoted over the rest of the 1/2-page article and a week later the headline was about costs climbing as more people enroll past the health act set deadline.

The administration is focused on the metric of increasing the number of enrollees; therefore, it has allowed large numbers of people to sign up past the deadline by creating “special categories” or “new onset circumstances” as a humanitarian response. However, once the medical emergency is over, these folks drop out after a temporary subsidization. These temporary riders, so to speak, are, according to insurers, harming and destabilizing the exchange markets. The Feds set up these post-deadline circumstances for eligibility, but provided no support, nor guidance, to verify that this cohort actually qualified.

Behind the ideological sniping, there is accumulating more and more evidence that the economic premise of universal coverage, i.e. large pools of insured made up of multitudes of the young and healthy to offset the older and sicker, and efforts to eliminate waste and fraud, may not be attainable as this bill is implemented. Where is the political will and expertise to be found to fix it?

By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton

Why Would a Doctor Abandon a Steady Paycheck to Become an Entrepreneur?

As physicians, we are expected to be compliant with rules, restrictions, and regulations. We are expected to be risk averse. We are expected to be “providers,” but not necessarily innovators or leaders. As the healthcare system becomes increasingly consolidated into large overcrowded clinics, we are required to perform to the standards set by bureaucrats and clinic managers. These rules are often at odds with the best interests of patients and with our sanity.

The Alienation Of America’s Best Doctors

The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage.

Better to Live and Die in the U.S.A.

The United States healthcare system is often berated for how it treats patients near the end of life. They are purportedly attached to tubes and machines and subjected to unnecessary invasive procedures that cause inordinate pain with no potential benefit, there is underutilization of more compassionate hospice services. This “travesty” is expensive, as the care of dying seniors consumes over 25% of Medicare expenditures. We hear this story so often; it is almost taken as gospel-- but is it actually true? Is it more expensive and invasive to die in America than in other developed countries?

Gun Ownership and Doctors?

According to the Pew Research Center, there are approximately 32,000 gun-related deaths annually in the United States; 19,000 are suicide, 11,000 are homicide, and the rest are accidents, police shootings or of unknown causation. Moreover, there are more than 78,000 nonfatal gun wounds each year. Given the disproportionate number of victims that are less than 40 years of age, the morbidity and mortality of gun violence is significant. Physicians are involved with many types of public health issues, but few are as controversial or divisive as gun safety. Is it really an issue that falls within the medical domain?

High Depression Rates in Resident Physicians — Fact or Fiction?

The December 8, 2015 issue of JAMA had a startling key clinical point; the prevalence of depression or depressive symptoms among resident physicians in training was 28.8%. The data was generated by meta-analysis of 31 cross-sectional and 23 longitudinal studies published in peer-reviewed journals involving 17,560 trainees. Two-thirds of the trainees were in North America, but the others were from Asia, Europe, South America, and one from Africa. Sensitivity-analysis confirmed that no individual study affected overall prevalence by more than 1% and that the incidence of depression was not influenced by study design, continent of origin, surgical vs nonsurgical program nor level of residency year.

Can a Robot Outperform Your Surgeon?

In the current competitive environment, healthcare providers often attempt to separate themselves from their competition by marketing themselves as using the newest technologies for their procedures. This is an age defined by finding the next best thing and the American public responds to this strategy. My personal experience has been in cardiac surgery, but the principles are equally applicable to other specialties, particularly tertiary referral practices.

Hospital Administration Attempts to Cut Costs and Increase Quality at Expense of Physicians

A nonprofit hospital care system in Oregon with 450 beds has been in an acrimonious negotiation with its staff hospitalists for the past 2 years. The mounting economic pressures on this small, community oriented institution have had the expected consequences of hiring new administrators to implement the latest trends to rein in the budget and effect efficiencies of healthcare delivery-- as if that has been so successful in the rest of the country. The battle has really centered over the physicians losing control of their work time allocation, individual decision-making for diagnostic and treatment plans, as well as bristling at bonuses based on the administration’s definition of quality.

Michigan Physicians Society Supports Inner-City Education

Yesterday afternoon I had the privilege of helping to honor the graduating class of 2016 at Experiencia Preparatory Academy. They have 3 graduates this year that have overcome a special set of challenges, including moving from Mexico to the United States and having English as a second language.

Affordable Care Act: Affordable for whom?

Entering its third annual open enrollment period, Obamacare is the subject of cacophonous political acrimony, again, championed by its supporters and vilified by its opponents. Each side presents its own “metrics” of success or failure

Big Pharma Using Mail-Order Pharmacies to Maintain High Prices

The United States has the dubious honor of paying the highest prescription drug costs in the world. Many healthcare economists attribute this to relatively lax cost regulation compared to other wealthy countries; however, a decade of insurers paying only for generic drugs when available and limiting drug choice in specific formularies has had little modulating effect.
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